Management of Gastric Cancer

Diagnosis and Staging

The National Comprehensive Cancer Network recommends diagnosis of gastric cancer from gastroscopic or surgical biopsy reviewed by an experienced pathologist, with histology reported according to World Health Organization criteria 2
90% of gastric cancers are adenocarcinomas, divided into diffuse (undifferentiated) and intestinal (well-differentiated) types 2
Comprehensive staging should include physical examination, blood count and differential, liver and renal function tests, endoscopy and CT scan of thorax, abdomen, and pelvis, endoscopic ultrasound (EUS), and laparoscopy with/without peritoneal washings 2, 3
Staging should follow the TNM system and AJCC stage grouping, with a minimum of 15 examined lymph nodes (optimally at least 25) recommended for adequate staging 1, 2, 3

For Stage I disease, primary surgical resection with appropriate lymph node dissection is recommended, with endoscopic resection considered for select early gastric cancers (T1a) with low risk of lymph node metastasis 2, 3
For Stage II-III disease, a multidisciplinary treatment planning approach is mandatory, comprising surgeons, medical and radiation oncologists, gastroenterologists, radiologists, and pathologists, with perioperative chemotherapy, postoperative chemoradiation, or adjuvant chemotherapy considered 2, 3, 5, 6
The American Joint Committee on Cancer recommends that the extent of lymphadenectomy be optimized, with a minimum of 14 and optimally at least 25 lymph nodes recovered 3

Surgical resection is the only potentially curative treatment for stages I-IV M0, with the type of gastrectomy depending on tumor location and extent 3, 5
The National Comprehensive Cancer Network recommends that laparoscopic surgery be considered for distal gastrectomy, with careful study and audit recommended as experience develops 5

The American College of Radiology recommends preoperative or postoperative radiation therapy as part of multimodality treatment, with a standard postoperative dose of 45 Gy in 25 fractions over 5 weeks 2, 6
The National Comprehensive Cancer Network recommends that target volumes include the tumor bed, anastomosis, and regional lymph nodes at risk, with every effort made to keep lung volume and doses to a minimum 2, 7

The MAGIC trial demonstrated a benefit of perioperative ECF chemotherapy, with improvement in 5-year survival from 23% to 36.3% 2, 5
The Intergroup 0116 trial showed a benefit of postoperative chemoradiation, with a 15% improvement in 5-year overall survival 3, 6
The ACTS-GC trial demonstrated a benefit of adjuvant S-1 chemotherapy after D2 dissection, with improved 3-year survival (81.1% vs. 70.1%) 6

The National Comprehensive Cancer Network recommends endoscopic hemostatic interventions for acute bleeding, with interventional radiology angiographic embolization considered when endoscopy is not helpful 1, 7
The American College of Gastroenterology recommends establishment of enteral access for hydration and nutrition if endoscopic lumen restoration is unsuccessful, with external-beam radiation therapy and chemotherapy considered for symptomatic relief 7

The European Society for Medical Oncology recommends regular medical examinations, assessment of performance status, and body weight monitoring, with blood tests including tumor markers, CT and/or ultrasound imaging, and endoscopy at regular intervals 4